Hartland Eye Care - Optometrist In Hartland, MI USA

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Date of Last Eye Exam

Primary Vision Coverage

Secondary Vision Coverage

Primary Medical Coverage

How did you hear about our office?

Prior PatientDoctor Referral (Write name in box below)Friend (Write name in box below)Yellow PagesSaw Sign / BuildingInsurance ListingWeb PageOther (describe below)

Name of person who referred you.

Allergic/Immunological

Medication / Purpose

If yes, year of diagnosis

Are you allergic to any medication?

Medications I am allergic too:

Name of Primary Care Physician:

Macular Degeneration

Have you had any eye surgeries, injuries or serious conditions?

If yes, please describe below:

Do your eyes ever feel dry?

If yes, please explain your dryness symptoms;

Do you wear (check all that apply)?

Prescription GlassesComputer GlassesPrescription SunglassesNon Prescription SunglassesSoft Contact LensesHard (Gas-permeable) contact lensesNon Prescription Reading Glasses

Tell us what you want to learn more about during your visit(check all that apply).

Prescription GlassesComputer GlassesPrescription SunglassesNon Prescription SunglassesSoft Contact LensesHard (Gas-permeable) contact lensesLasik SurgeryGentle Molding (non-surgical vision correction)Dry Eye Treatment

Do you use a computer?

Number of hours per day?

Distance from eyes to computer in inches?

Are there any times when you wish your vision was better?

If yes, please describe below.

Please tell us anything you would like us to know about your visit so that we can better serve you:

Enter the verification code in the box below.

Verification Code: *

Adult History Form

Medical History

Have you had any of the following health problems?

List your medications followed by what they are for (ex. Insulin/Diabetes).

Family History

Personal Eye Information

Is there anything we forgot to ask?

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